NCC191209_Contact Update Record (Email Only)_20230316

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by bethany.georgoulias 3/16/2023 12:54:16 PM (Contact Changes Submitted)

Certificate of NCC191209
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
NC Reference No. NCG01-2019-1209
Original NOI No.* 14470
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new COC required)
CLINARD FARM PARTNERS, LLC
Project Name BRYSON PARK 4-5
Address HEGE ROAD. ARCADIA TOWNSHIP. NC
County Davidson
Latitude 35.9693
Longitude-80.2728
Date COC Issued * 08/09/2019
Prior Rescission Date This field will populate only if COC has already been rescinded.
Which Contacts Have Billing Only
Changed?* Legally Responsible Individual Only
Site Contact Only
BOTH Legally Responsible Individual and Site Contact
Has Billing Contact Choose'Yes'to revise Billing Contact details.
Changed? OQ No
0 Yes
Billing Email [e-mail]
Billing Telephone No. [phone]
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible CHRISTOPHER LYONS
Individual (Previous)
First Name (New)* CHRISTOPHER
Last Name (New) * LYONS
NEW Legally Reflects any revisions above
Responsible CHRISTOPHER LYONS
Individual*

Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No. (Previous)
NEW Permittee 336-279-7280
Telephone No.*
Permittee Mailing 110-A Shields Park Drive, 0, Kernersville, NC
Address (Previous) 27284
NEW Permittee Street Address
Mailing Address* 110-A Shields Park Drive
Address Line 2
City
State / Province / Region
Kernersville
NC
Postal / Zip Code
Country
27284
us
Permittee Street 110-A Shields Park Drive, 0, Kernersville, NC
Address (Previous) 27284
NEW Permittee Street Street Address
Address * 110-A Shields Park Drive
Address Line 2
City State / Province / Region
Kernersville NC
Postal / Zip Code Country
27284 us
Change Requested Jason Cheek via email on 3/16/2023. Email correction only.
by: * Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date * 03/16/2023